the truth about the Parliamentary and Health Service Ombudsman

Beyond the yellow brick road. Allyn Condon’s fight for justice.

Editors note: As you follow the ‘yellow brick road’ on Allyn Condon’s fight for justice for his baby son’s avoidable death you will find that the NHS story keeps changing and changing again. Despite hard evidence of the failure of Bristol Children’s Hospital they have obfuscated at every turn. Deny, delay, defend in action. You can follow Allyn Condon’s journey here

To all NHS staff if you have the time to read the following it may inform you in some of your future decision making, in regards to your patients and their families. I hope in some part what I have written can be of help to you and the future of the NHS.

I must first state that my intention in writing this letter is not to in anyway harm or harass anyone and not to cause any alarm or distress. All information provided in the document is truthful and therefore will not constitute any libel, defamation or any other similar claim.

My aim is not to be vexatious, nasty or personal but merely to present facts of the matter allowing people to make up their own mind and to use the information as they see fit.

The path which I am currently on was chosen by NHS staff, not myself, or any member of our family. Unfortunately this path does not have yellow bricks or an Emerald City at the end of it, of that I can assure you.

I have however offered on many occasions the opportunity for NHS staff who chose this path, a way to get off and that is by offering the truth, a truth that should have been offered from day one but wasn’t. Nevertheless I would once again state that without the truth it will take more than the wonderful Wizard of Oz to put an end to this journey.

I have followed recent medical cases and one in particular and it was clear that the outcome was not a big favourite with the NHS fan club. An outcome that has been fiercely contested. From my little knowledge as a mere mortal I have gathered that there have been several breakdowns and misunderstandings along the way.

Based on my above experience I would like to once again publicly offer all involved in our own case, the opportunity to stand up and break ranks by coming forward and being honest. A big ask I know but if you don’t ask, you don’t get. For anyone involved, I offer the opportunity to be removed from any further involvement in what has already turned out to be a messy case. For those involved in the case who wish to remain silent, then that is indeed a choice that will no doubt come with future consequences and I hope that the consequences are not met with outrage and anger from the NHS fraternity who will be able to recognise that several windows of opportunity were given for the truth to be told.

Now I must reiterate that my intentions are not to cause any harm or distress or to harass any individuals and my actions must certainly not be constituted as a threat but how shall we say it, more of a promise. I will pursue this for as long as it takes and along the way I will ensure I publicly expose those involved over and over again with factual evidence. I will be relentless in my pursuit of justice at whatever cost. My actions may appear futile in the rose tinted eyes of some NHS staff, but to me, it is the opposite action that is being used to meet the original action.

If you know any of the people involved and feel it may be within there interest then feel free to forward on this letter and maybe one day they will thank you for helping them out. Maybe one day as a valued worker within the NHS you may also recognise the choices they made were the wrong ones and the consequences which followed could have been avoided with the truth.

So let me explain exactly what I am talking about.

NHS staff were responsible for the death of our two month old baby boy Ben, a death they subsequently covered up. Some will argue that they never covered up his death they covered up the negligent failings which led to his death, potato potahto.

The level of care they offered our son on the intensive care unit at Bristol Children’s Hospital fell way way way below the expected level, to a level we believe is criminal. Now I know some medics at this point will be sighing that another family are pursuing the excellent staff that just made a little mistake but hear me out.

Whilst Ben was on the PICU ward in Bristol, staff failed to appropriately monitor his temperature leaving him hypothermic for days on end, failed to appropriately monitor his ventilation despite his condition requiring optimum ventilation management, told us Ben was of no concern to them and that others could die, showing a total lack of respect and total complacency around Ben’s illness. Staff failed to carry out appropriate or regular monitoring despite the suspicion of a bacterial infection waiting over 40 hours to take tests, twice. Failed to carry out blood tests despite saying they had, failed to carry out blood cultures despite saying they had, failed to administer antibiotics for 3 days despite suspecting a bacterial infection, failed to take any action after Ben turned blue and wasn’t ventilating, left him without senior care for 6 hours whilst blue and deteriorating, decided to give antibiotics but failed to do so for 9 further hours, prescribed antibiotics for chest Sepsis and forgot to give them for a further 6 hours, administered a drug days outside protocol causing collapse and hours later Bens death.

Now I think any credible medic will agree that the standard of care fell way below what was expected, especially considering Ben was on what would be considered by some to be one of he most reputable children’s wards in the country. Any medic who disputes this falls way below an expected level, has no place in our NHS. Facts are facts.

So what else did they do?

After discovering a positive bacterial infection, they failed to tell our family about the result for 12 months, yes 12 months. They failed to add any reference to the bacterial infection in any medical records before, during or after Bens death, failed to carry out a post mortem after telling us one was not necessary, failed to add the hospital acquired infection to the death certificate. Staff also failed to contact the Coroner claiming that the death was expected despite all Doctors stating they were shocked when Ben died and it was unexpected.

So we all make mistakes and we all forget a few things here and there so I don’t want to be too hard on these Doctors. I mean surely they would just tell us what happened and we could all live happily ever after.

They failed to provide us with a discharge or death summary, failed to offer any bereavement support, failed to contact us after Ben died and later claimed they had but claimed they never left a message as they didn’t want to bother us.

We then met Consultants 7 weeks after Ben died were they finally told us 50 minutes in to a meeting that Ben had developed a secondary bacterial infection. The honesty was overwhelming. They then went on to lie saying they never knew about the infection until long after death, lied telling us they had carried out blood tests and blood cultures and lied stating the both bloods and cultures were negative. No tests were ever taken when they claimed. We also know it was the infection that brought the Consultants to the bedside. How does something bring you to the bedside that you claim to only have known about 12 months after death. Honestly I am not kidding 12 months after death they disclosed the result that was reported hours before Ben died. You couldn’t even make it up if you tried.

Following the meeting where they told us they never knew about the infection before Ben died they later sent internal emails discussing the positive result before death. Good honest Doctors. More lies.

They were investigated for their lies. The outcome was they didn’t mean to lie. The person who investigated them was one of their colleagues. They were that close she failed to even take a statement off one Doctor. An independent investigation decided the investigation was not appropriate or robust. No further investigation was done.

The Chair of Child Death Review removed references to failings, references to deteriorating blood results, references to inappropriate ventilation management and references to hypothermia. She also withheld the Child Death Review minutes for 18 months, coincidentally until one week after the inquest, claiming they did not exist. When we finally received them they disclosed more recognition of failings and failures in protocol. It was finally admitted in the Child Death Review that Ben had died of Pseudomonas, Pseudomonas Sepsis, Sepsis Syndrome, Septicaemia, Sepsis. Interestingly enough despite it being a hospital acquired infection the microbiologist claimed that the infection had come from our home water and refused to accept it was hospital acquired. I think the tests on admission they did, or claim to have done may prove that theory wrong.

A further meeting we discussed in detail Bens care and discussed the poor level of care. We discussed that it was disgusting that Ben wasn’t given antibiotics and was told that they had forgotten, but that they were also not necessary. We left the room and staff admitted that we were right and that antibiotics should have been given days earlier. We know they admitted this because they were recorded, not only on our recording but also on their own. After they admitted we were right they realised the recordings were still on and conspired to delete the hospital recording and attempted to delete our recording. Unfortunately they failed to delete ours so therefore could not delete their own despite agreeing to delete it after the meeting had finished.

They were investigated for conspiring to delete the recordings. The outcome was they didn’t mean to say it and there comments were said in haste. The person who investigated was one of their colleagues. An independent investigation decided the investigation was not appropriate or robust. A further investigation was done coming to the same conclusion. The Trust refused to release the investigation stating it was on the advice of their legal team. Open, honest and transparent? You make up your own mind.

The investigator removed all reference to failings stating they were not relevant. Candour? I think not.

In a further meeting the silence was broken. They admitted, we got it wrong and we are sorry. We missed the infection and we are sorry for not getting in and treating it. We should have given him antibiotics days earlier and had we done so they would have treated him. They admitted that all involved agreed that Ben should have been given antibiotics earlier. They agreed that when Ben was blue that was the Sepsis getting hold of him. They told us that they were not covering. This was six months post mortem. Imagine being a family and hearing this. A mixture of hurt at knowing he could have been saved and relief that we now knew.

From this day onwards they changed their mind, they changed their story. From when they admitted they should have given antibiotics, apparently he no longer died of an infection.

An inquest 18 months after Ben died they all told the Coroner there was never any sign of an infection, antibiotics were never needed and antibiotics would not have saved Bens life. They all told the Coroner that Ben died of an air leak around his heart, an air leak that caused a cardiac arrest and caused Bens death. What they told the Coroner was more lies. Interestingly enough the Coroners own independent expert told the same lie. Collusion? Not for me to say.

They knew they had administered a drug Day’s out of a documented protocol which had caused the air leak and the cardiac arrest but claimed Ben had deteriorated with an air leak before the drug was given. This was despite previously telling us that Ben was stable at this stage. But that was the other story. More lies, more inconsistencies and most of all absolute perjury committed by all Consultants at the inquest. The Coroner said she was not willing to comment on their lies.

They told us he had an infection they missed, they told the Coroner he didn’t. They told us antibiotics would have treated him, they told the Coroner they wouldn’t. They told us antibiotics should have been given earlier, they told he Coroner they shouldn’t. They told us there is no way we can say he had an air leak before he had a cardiac arrest, they told the Coroner the air leak caused the arrest. More lies and more cover up, absolute perjury.

They told us the Pseudomonas infection had brought Consultants to the bedside and they told the Coroner they knew about the infection that night. We know there are five Doctors who knew about that infection before Ben died. The Trust claim it was only a trainee who knew and he took no action. They knew and the Trust CEO still claims today that they didn’t. They won’t admit they knew because when they do we start again. Why did you not document? Why did you not tell the parents? Why was it not on the death certificate? Etc etc. Let’s just blame the trainee who has currently been left out of the picture but will no doubt be pursued at some point for his lack of effort to take action on a dying baby after he found out he had an infection.

Oh and just to top all this off after two and a half years they finally admitted liability for the negligence that led to Bens death and claim they had only just realised.

Now after all of the above I once again offer each and everyone of them an opportunity to clear their name, to be honest and to do exactly what should have been done from day one. If they are being forced to lie then say so and we will leave them alone. Of course they need to say who by. If they feel out evidence is wrong, just let me know I will remove it.

Dr Jess Spaull Junior Doctor

Dr Suzanne Dean Paediatric Consultant

Dr James Fraser Paediatric Consultant

Dr Matthew Christopherson Paediatric Consultant

Dr Peter Davis Paediatric Consultant

Dr David Grant Paediatric Consultant

Dr Margrid Schindler Paediatric Consultant

Dr Ian Jenkins Paediatric Consultant

Bryony Strachan Chair of Women and Children’s Services

Rebecca Dunn Deputy Divisional Director

Ian Barrington Divisional Director

Sean O’Kelly Medical Director

Robert Woolley Chief Executive

Profession Michael Stevens

Dr Jane Luker Deputy Medical Director

Each and every one of the above have played their role either negligently allowing Ben to die, causing death through reckless practice, conspiring to cover failings and delete evidence, inappropriately investigating covering failings, withholding evidence, lying about failings, lying about test results & perjury.

I will continue to expose each and everyone now and forever more with factual evidence. If what I was saying was not true it would be removed and I would be in court for defamation. Ask yourself why I am not? I was arrested twice for harassment for exposing them. The cases were dropped. It was just an attempt to discredit me and my own unblemished character.

I will ensure that all future employers are aware and all family and friends. I am not harassing anyone, I am presenting facts. I will be like the news channel in their life that never turns off presenting old news over and over again to new people. I will keep going until everyone knows, every colleague and every person.

If anyone believes anything I have written is incorrect and would like to discuss it and prove me wrong I will remove it.

I hope they take me up in my offer, it may save their careers. I hope that other medics realise that lying and covering a baby’s death is not cool, it ruin lives. Think before you lie.

This is not Kansas and I am not Dorothy.

This is real life and Ben was a living breathing little boy who they left to die and covered up his death.

These Doctors are not the victims of my repetitive campaigning, they are the victims of their own selfishness. They are what is destroying the NHS whilst people sit back and blame everything else.

Ask yourself, is this the NHS you signed up to work in? Are these the people you thought you would be working with?

This is not system failure due to shortage of staff or any other reason. This is individual failings and individual lies that have failed the system, failed the NHS and failed our family. There are no excuses!

You have my sympathy for your dilemma. At age 74 I was admitted to an NHS Trust as an emergency three hours after a doctor had decided to discharge me as he claimed I had acopia. I spent two months in that hospital being treated for sepsis. I have been disabled ever since and still suffer from post sepsis syndrome.

I reported my concerns to Parliament on July 4th. 2016. Nothing happened

I now have evidence of 16 staff , the Chief Nurse and the Chief Executive of that Trust all of whom covered up for the negligence of the doctor in A&E and the consultant who later refused to treat me. The evidence is contained in internal e mails between staff and doctors. Which the PHSO investigator refused to consider in evidence he had on file.

Allyn keep up your fight for disclosure and accountability. It is the only way that somebody else’s child or another patients life can be saved.

Heartless and hopeless. Let’s hope continued lobbying of the Government will eventually ensure a decent pathway for mistakes doing away with unnecessary distrust/hostility between patients and medics! Sometimes dreams do come true…

The cracks are showing but the it’s the denials and skeletons in the cupboards which will finally show were wee are with PHSO Behrens, just as it did with Mellor, the way I see it.

I’m asking why PHSO just relied on lies without questioning or checking, from the clinician ‘team’ at BSMHFT responsible for my son’s negligent care 12-7 years before.

Behrens is running scared of yet more damaging exposures. Smirking in the face of more patient deaths, is my impression. Not a care to fix the corruption of purpose – just more buddy-cooperation with NHS CEOs as evidenced in my unresolved case.

“Listening” You are quite right. I am just discovering with an NHS Trust in Croydon Data Protection office that they cannot trace my medical records for the past three years because they have been stored on 5 different computer systems which do not provide information to each other.

Also because I live in Surrey and Croydon is in Greater London there is no way that medical records cross refer because they all have different computer systems.

This is all down to total negligence and incompetence in the administration of the NHS England who allow their contracted parties , namely Trusts and G.P.s to have their personal choice of what technology to use.

This kind of persistent failure to communicate over many years makes a major contribution to the deaths and mistakes made by clinicians , who act in good faith , and then spend the rest of their lives covering up for errors which may not always be their fault.

So so sorry for the miserable death of your child. We are all tribal. Ranks close against any “outsider” regardless of personal feelings. I’ve had three years of it. No clinic notes, consultant retired,etc. I was a young child when my mother and my aunt, both nurses, told me about this marvellous new NHS.Awful the way things have worked out. The ressponsibility lies with the Health Secretary, the Trusts(good name that) and hospital management. Read,”This is going to hurt” for an idea of the way it is for the staff. Read Geoffrey Wests book called,”Scale” The Lifespan of humans,cities and companies. If you see the NHS as a company they have a one in many million chances of being around in 30 years time.Someone should write a book about the sise and fall of the NHS; won’t be me. Carry a notebook and pen to every visit. Have someone with always.I’ve thought of recording everything said;don,t know if it’s legal. Get copies of test results fro hospital records.Used to charge but don’t anymore. Get copies of scans,if you move from one Trust to another-really useful.Cover you and yours in every possible way.Stay safe.

I live in Surrey with a GP in Surrey and in the past year have had treatment in hospitals in Epsom and Croydon. I have had to provide copies of my own medical records to Epsom and Croydon Hospitals as they have no means to access my medical records in Surrey .

This is symptomatic of the entire NHS where each Trust has a different computer system and indeed the large Trusts have several different computer systems which are not compatible with each other.

I was in East Surrey Hospital , Redhill out patients last week end and I noted that the computer used to record patients records was still operating on Windows 7.

This system is now obsolete and Microsoft will no longer be keeping it secure as from December 2019 .

We have not got a National Health Service at all. It is a series of incompetent administrative Trusts and GP practices all contracted out by a Government Agency called NHS England . It is a national scandal and a national scam. !